Medical Murder: Disturbing cases of doctors who kill

Prologue

In January 2000, world-wide headlines announced that English general practitioner Dr Harold Shipman was found guilty of murdering fifteen of his patients. Before his trial, many had assumed that Shipman was an overzealous doctor doing no more than ‘easing the passing’ of dying patients. But the evidence showed otherwise; Shipman deliberately murdered not just fifteen, but several hundred patients in the most efficient mechanical and indifferent fashion, making him a hitherto unparalleled medical serial killer.

Shipman’s American epigone, aspiring neurosurgeon Dr Michael Swango, spread his net across the US, Zimbabwe and Zambia, leaving a trail of bodies in his wake. Sydney psychiatrist Dr Harry Bailey killed close to a hundred patients with Deep Sleep Therapy, a discredited and dangerous form of treatment. Dr Radovan Karadzic, the psychiatrist who led the Bosnian Genocide, shelled the hospital in Sarajevo where he had worked, killing colleagues and patients.

The phenomenon of medical killing has been largely ignored and there has been no attempt to understand the basis for such extreme behaviour. In this book, I explore clinicide—a new term—defined as the death of multiple patients in the course of treatment by a doctor. The study of clinicide raises powerful and disturbing questions: why do doctors deliberately kill their patients, ignore appalling death rates, or use their medical skills to participate in horrendous experiments, torture or genocidal murder in the service of the state?

Medical murders are appalling but unusual crimes. It is a paradox, considering the extraordinary effort, discipline and devotion that it takes to become a doctor when throughout history medicine has been regarded as a sacred calling. While the incidence of medical killing is very low, this is little consolation to the victims or their families.

I have examined clinicide in the context of the history of medicine, forensic psychiatry and sociology. The role of the healer, medicine man or doctor is universal and little, aside from advances in technology, will change this. The motives of doctors are as much an expression of the prevailing culture as scientific progress which, in many cases is suborned by its practitioners for all too-human motives.

I explore medical killers over time, focusing on Harold Shipman, Michael Swango, Harry Bailey, John Bodkin Adams and Radovan Karadzic.

That some doctors become killers says much about human nature, society and the practice of medicine. But it should be remembered that very, very few members of a great profession follow this path. The practice of medicine is an inherently good activity, and it is to the credit of the profession that there are so few killers. I hope this book will make a contribution to keeping it this way.

Robert M. Kaplan

March, 2009

1

The rise and fall of the

medical calling

The most incisive words on medical murder were written in 1978 by forensic pathologist Keith Simpson:

Doctors are in a particularly good position to commit murder and escape detection. Their patients, sometimes their own fading wives, more often merely aging nuisances, are in their sole hands. ‘Dangerous drugs’ and powerful poisons lie in their professional bags or in their surgery. No one is watching or questioning them, and a change in symptoms, a sudden grave ‘turn for the worst’ or even death is for them alone to interpret.

Doctors, Simpson pointed out, authorise the removal of a dead patient by writing the death certificate. If they take the law into their own hands, it is only likely to emerge through chance, whisperings or rumour, or careless disposal of the body. That medical murder emerges so seldom, considering the number of practitioners, is either a testimony to their moral fibre or the ease with which they can conceal crime.

English psychiatrist Herbert Kinnell rates doctors as the greatest killers among all the professions. Doctors as a group are murderous: they kill family and friends; they kill their patients; and they kill strangers, chiefly for political reasons, by torture, mass murder or genocide.

Medicine has always had an attraction to those interested in power over life and death, status and the acquisition of wealth. The first factor in its appeal to potential killers was the institutionalisation of medicine. Legitimisation put the medical profession in a position of power, authority and status it has ever since been reluctant to cede, a built-in factor attracting a certain kind of psychopath.

As the nature of medical practice changed, the number of doctors being trained expanded in tandem with the population. Welcome as this development was—because it meant the medical population was more representative of the community—it increased the possibility of someone who was a completely unknown quantity graduating and going into practice. Before, say, World War II, a psychopathic individual intrigued by exploiting the power over life and death in this setting would have had to choose a low-status alternative career, or even fake their credentials. After institutionalisation there was no need for these machinations; with a little effort, medical schools became an open market. Dr Marcel Petiot, for example, who worked in the early part of the twentieth century, only had eight months’ training when he came out of military service. Linda Hazzard, who killed numerous people with starvation diets in the United States and New Zealand, had a dubious osteopathic qualification and was allowed to call herself a doctor by virtue of a grandfather clause in one of the states where she worked.

In a setting where medical practice is defensive and insecure, to say the least, there are any number of opportunities for the psychopathic doctor. And the reckless treatment killer, driven by mania, narcissism or hubris, can find any number of cracks in which to insert themselves in the medical edifice.

Clinicide means the death of numerous patients during treatment by a doctor. Like any crime, clinicide is a complex behaviour affected by social, cultural, psychological and forensic factors. Just as the classification of illness and the practice of doctors reflect the society in which they occur, so do the circumstances of clinicide.

Clinicide can be divided into several categories:

Medical serial killing

The image of a ‘serial killer’ is not a medical doctor in a white jacket. But when doctors turn on patients because they derive some perverse pleasure from the act of killing, they tend to be prolific murderers. While reckless, incompetent, inept, mad or just plain dangerous doctors have been around for as long as medicine has been practised, medical serial killing is a relatively new phenomenon. Serial killers are obviously not mentally balanced individuals. Nonetheless, there is a certain inner rationality to their actions—they know that they are engaged in murder, and they go to great lengths to plan out the continued fulfilment of their murderous fantasies.

French doctor Marcel Petiot left a trail of bodies wherever he practised. His period of destruction probably extends from 1926 (if not before) until 1944, and an estimate of 100–200 victims is reasonable, making him the worst serial killer in French history. Dr Harold Shipman, easily the worst serial killer in the United Kingdom, was killing patients from the time he went into practice in 1974, continuing with only a year’s break when he was receiving treatment for drug addiction, until his arrest in 1998. Dr Michael Swango killed 60 patients from the time of his internship in 1983 until he left Zambia in 1996 (with several years away when he was in jail and out of practice). Between them, Shipman and Swango are credited with at least 313 deaths. The worst Scandinavian serial killer is Dr Arnfinn Nesset,¹ credited with 137 murders within half a decade. These figures are far in excess of what the average serial killer attains, and reveals just how dangerous a medical serial killer can be when unleashed.

Treatment killing

Treatment killing refers to multiple patient deaths in which it is not immediately obvious that the doctor intended the patients to die. A separate category is merited because the question of intentionality (motivation) and self-awareness of the harmful nature of the action is blurred in these cases. Treatment killers are either doctors who are mentally impaired, or those who do not have a mental illness as such but view their patients as mere accessories to their own grandiose role, no more than objects who ought to be grateful for any treatment they receive, regardless of the outcome.

Doctors with serious mental illness are a problem as old as medicine. When a prominent physician or surgeon is involved, it is described as an example of the ‘Great Man syndrome’. These doctors have such authority and charisma that underlings are always reluctant to challenge them to stand down—and they are even less likely to obey when told.

Treatment killer doctors only achieve recognition, and most reluctantly so, when the extent of the deaths associated with their treatment becomes exposed to the public. There is shock, horror and outrage, often leading to disciplinary inquiries or manslaughter charges. To the onlooker, investigator or general public, this is predicated on the idea that incompetence, wilful or witless, caused the patient deaths, and they were not deliberate or intended. As the courts put it, there is no apparent motive.

Such doctors develop a God complex, getting a vicarious thrill out of ending suffering and determining when a person dies. Peter Smerick, former FBI criminal profiler, describes two types of treatment killers:

1. The Hero Killer doctor would put a patient under great risk. If they save the patient, they are a hero. If the patient dies, the killer will say ‘So what?’

2. The Mercy Killer doctor will rationalise that they are concerned about the suffering of their patients and put them out of their misery. They count on the fact that autopsies are usually not performed when a terminally ill patient dies.

Doctors, particularly specialists, are not only trained but expected to provide optimum care at all times, to seek help or second opinions regardless of vanity or fear of criticism. Their role is to take responsibility for the patient’s care as far as can be reasonably expected. When the death list progresses beyond two, or four or twenty patients, it is not possible for a doctor to continue treating patients without some awareness that they may cause death. At some level, these doctors realise what they are doing, but this is countered by an overweening refusal to acknowledge the reality or desist. Denial alone can’t explain why a surgeon or psychiatrist can ignore death after death after death of patients under their care. The cases of Dr Ferdinand Sauerbruch, Dr Hamilton Bailey and Dr Harry Bailey show how treatment killers operate.

Mass murderers

Mass or political murderers fall into another category. Their activities are so extreme and appalling that attempts to portray them as serial killers operating on a wider front are misleading. Doctors have frequently been accomplices in state-led repression, brutality and genocide, in direct contravention to their sanctioned role to relieve suffering and save lives. Doctors have performed inhumane experiments on victims, participated in torture and directed programs to exterminate the enemy. In addition, they have beaten, tortured and killed victims for no other reason than they had the power to do it at the time, and gave every indication of enjoying what they did. In doing so, they became mass murderers on an exponential scale, making any comparison with a doctor killing his own patients untenable.

In the last decade, there have been any number of reports of doctors participating in state abuse of human rights, usually in their treatment of detained enemy suspects. The most recent example of this is Dr Radovan Karadzic, a practising psychiatrist who led the Bosnian Genocide. Forces under Karadzic’s direct command were responsible for mass atrocities, leading to 250 000 deaths and up to one million homeless. What’s more, Karadzic’s motivation was not purely political as he used his psychological training to direct terror tactics.

While these three categories of clinicide differ greatly, they all share one element: although society places an enormous amount of trust in doctors to prevent harm and promote health, these perpetrators violate that trust in the most shocking and horrific manner.

A physician is obligated to consider more than a diseased organ, more even than the whole man—he must view the man in his world.

Harvey Cushing

In order to understand clinicide, it is important to understand the terrain in which doctors operate: the medical profession, its history and culture. Seeking treatment for an illness or injury is a specifically human activity. It requires a sense of being unwell, and desiring to alter this. Dr William Osler, the most famous physician of his time, went so far as to state that ‘The desire to take medicine is perhaps the greatest feature which distinguishes man from animals’. This produced homo therapeuticus, the medicine-taking animal: you and me.

While this pill-popping perspective may reflect the particularly skewed vision of a physician, Osler had a point. Medicine, in the form of healing, has been with us for as long as we have been sentient human beings. Rock painting and engraving, which goes back 30 000 years, arose from shamanic trance states during healing dances. The shamans communicated with spirits for the purposes of healing illness, breaking drought periods, finding animal herds and promoting group cohesion. Healing involved the shaman drawing out the evil spirit that had invaded a victim’s body and expelling it through their own. Shamans extended their range to use herbal cures and potions, magic tricks, divining, tooth pulling, bonesetting and the first psychosurgery—trepanning skulls—to release evil spirits. Trepanning, or drilling holes in skulls, was often done to relieve the fatal pressure from a subdural haematoma. These ancient tribes had excellent antiseptic procedures and the primitive surgeon proved adept at putting the hole in the right place on the skull.

The shaman not only warded off death, but participated in group activities such as hunting, ritualised killing and, later, warfare. These activities were conceived as sanctioned healing for a higher purpose. The life of the medicine man (or woman) was by no means easy; failing to get the prediction right could mean becoming the next sacrifice of the chief, headman or king.

Modern medicine has retained: the tendency to meet the needs of a hereditary or elite class before attending to the masses; receiving the hostility of patients or relatives to the failure to ward off disease and death; and, despite their elevated status, doctors are susceptible to being scapegoated at the perception of failure.

As humans moved from hunter–gatherer communities to agricultural settlements, a distinct shamanic class arose. This was often a skill that was passed down to male relatives, but it wasn’t exclusively male. Suitable candidates were selected at a young age and tutored in their craft. Religion and society developed increasingly complex role specialisation but the shaman, in one form or another, continued to flourish.

Any reading of the Bible or Homer will confirm the status of prophets, healers and medicine men. New Testament exorcists, for example, operated by speech and touch. Jesus himself was a wandering healer and exorcist in the Galilean countryside, commanding evil spirits to leave the body of the afflicted person. Many of his patients had epilepsy or hysteria and, ironically, as his fame spread, his appearance at Galilean villages led to mass hysteria! The Gospels tell us that Jesus was constantly asked to heal the ‘possessed’, even though this may have interfered with his mission as a prophet. In the episode of the Gadarene swine, Jesus commands the demonic spirits to leave the tormented victim and go into the swine, causing the 200-strong herd to rush off the cliff into the lake and drown, leaving the riparian farmer most unimpressed, if not causing mayhem among the spectators. Even Jesus experienced the lack of gratitude from patients that healers have had to deal with since time immemorial.

In their death-defying capacity, doctors are the modern heirs of the shaman, witchdoctor, medicine man or healer. The medical profession dates back over two thousand years, with the first ethical principles laid down by the ancient Greek School of Hippocrates, and medical and surgical skills developed during the Arab era. However, much of what doctors did for their patients consisted of reheated ancient ideas, remedies or witchcraft, doing little more than giving a sense that something was being done.

Initially, there was no distinction between body and soul, or in more modern parlance, between mind and brain. In the West, souls, accompanied however reluctantly by their attendant bodies, were the province of the Catholic Church. The Church used doctors to extend its own power, thereby maintaining their exclusivity. At the height of the Spanish witch persecutions in the fourteenth century, doctors were mandated by the Church to examine suspects and organise torture to get them to confess to heresy.

The Church’s vice-like grip started to weaken with Renaissance discoveries of the structure and function of the body. Vesalius’s work on anatomy and Harvey’s discovery of the flow of blood were crucial in wresting medicine from the Church, putting it on the path to becoming a clinical science. Descriptions by Spanish doctors of the first recorded episodes of syphilis in the late fifteenth century, for example, reveal good skills in observing disease.

Despite these developments, medicine remained a fiercely contested domain. The eighteenth century was the high time of the ‘quack’. Quacks mostly came from marginal groups, such as Jews and gypsies, who depended on their initiative to get established. They were assiduous self-promoters, made sure they got to where the clients were and, in many cases, were a lot cheaper than doctors. Widely derided by doctors, quacks often led their medical colleagues who would then steal the remedies for their own use.

The distance between doctor and patient reflected the times. Until 150 years ago, doctors did little more than talk and hold a pulse, doling out medicine that was patently ineffective. Rene Laennec, unusually for a Frenchman, objected to having to put his ear on the unwashed but perfumed breasts of his female patients, so he invented the stethoscope, providing an objective distance between doctor and patient.

Somewhere during the time of Queen Victoria, all this changed. As medicine became scientific, the distance between doctor and patient vanished. It was a revolutionary step when the suitably diffident Royal Obstetrician, his head turned away, tentatively inserted a hand under the Royal Gown to perform a vaginal examination during Her pregnancy. From that time, no orifice was safe from invasion, regardless of embarrassment, discomfort or distaste.

For all the posturing about ancient medical colleges, the official recognition of doctors is a nineteenth-century phenomenon. Although it now seems an accepted fact that medicine and surgery are amalgamated, this was by no means the case in the past. Three different medical groups existed, competed and variously claimed to be superior and professionally ethical: physicians, surgeons and apothecaries. Alongside these bodies competed a range of other groups: quacks, charlatans, healers, tooth pullers, manipulators and massagers, herbalists and soothsayers.

Technology, population surges and fear of change led to a need for control and regulation. This manifested with the institutionalisation of police work, border controls and internal regulation of professions and trades. By 1900, the registration of doctors was an established fact in most countries, including the United States. The legitimisation of professional status was followed by the formalisation of medical training and qualification rules. In the United States, this required the Flexner Report to revolutionise the profession and ensure that medical schools were not hole-in-the-wall operations issuing fake licences, a regular practice in many states in the past.

The development of specialisation facilitated the rise of medical status. This started in France after 1820, no surprise in view of the domination of French medicine in the age of Pinel. The French had greater numbers of doctors associated with hospitals and teaching centres with organised health care—not for nothing is the word bureaucrat derived from that period. The British preference for generalists rather than specialists and resistance from the medical establishment meant it took them far longer to make these changes. However, political pressure led to the institutionalisation of obstetrics and, after the 1880s, there was an inexorable path to specialisation.

Regulation of the medical profession